|
Yes - EMS Arrival with Notification Level 2*
|
Facility
|
OP
|
$2,991.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
4962607
|
|
Hospital Revenue Code
|
683
|
| Min. Negotiated Rate |
$1,402.74 |
| Max. Negotiated Rate |
$5,610.97 |
| Rate for Payer: Aetna Commercial |
$2,799.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,675.15
|
| Rate for Payer: Aetna Managed Medicare |
$1,402.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,021.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,555.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,493.11
|
| Rate for Payer: Anthem Medicare Advantage |
$1,402.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,648.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,402.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,402.74
|
| Rate for Payer: Cash Price |
$897.30
|
| Rate for Payer: Cash Price |
$897.30
|
| Rate for Payer: Cigna Commercial |
$2,861.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,402.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,740.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,402.74
|
| Rate for Payer: Health EOS Commercial |
$2,768.47
|
| Rate for Payer: HFN Commercial |
$2,861.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,218.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,402.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,402.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,402.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,402.74
|
| Rate for Payer: Multiplan Commercial |
$2,488.51
|
| Rate for Payer: NAPHCARE Commercial |
$2,104.11
|
| Rate for Payer: Preferred Network Access Commercial |
$2,861.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,524.21
|
| Rate for Payer: Quartz Commercial |
$2,021.92
|
| Rate for Payer: Quartz Medicare Advantage |
$1,402.74
|
| Rate for Payer: The Alliance Commercial |
$5,610.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,402.74
|
| Rate for Payer: WEA Trust Commercial |
$1,710.85
|
| Rate for Payer: Wellcare Medicare |
$1,402.74
|
| Rate for Payer: WPS Commercial |
$2,303.97
|
|
|
Yes - EMS Arrival with Notification Level 2*
|
Facility
|
IP
|
$2,991.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
4962607
|
|
Hospital Revenue Code
|
683
|
| Min. Negotiated Rate |
$1,524.21 |
| Max. Negotiated Rate |
$2,861.79 |
| Rate for Payer: Aetna Commercial |
$2,799.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,675.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,648.64
|
| Rate for Payer: Cash Price |
$897.30
|
| Rate for Payer: Cigna Commercial |
$2,861.79
|
| Rate for Payer: Health EOS Commercial |
$2,768.47
|
| Rate for Payer: HFN Commercial |
$2,861.79
|
| Rate for Payer: Multiplan Commercial |
$2,488.51
|
| Rate for Payer: Preferred Network Access Commercial |
$2,861.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,524.21
|
| Rate for Payer: Quartz Commercial |
$1,866.38
|
| Rate for Payer: WEA Trust Commercial |
$1,710.85
|
| Rate for Payer: WPS Commercial |
$2,303.97
|
|
|
Yes - EMS Arrival with Notification Level 3*
|
Facility
|
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
4962608
|
|
Hospital Revenue Code
|
683
|
| Min. Negotiated Rate |
$1,000.90 |
| Max. Negotiated Rate |
$5,610.97 |
| Rate for Payer: Aetna Commercial |
$1,876.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,793.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,402.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,355.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,042.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,000.90
|
| Rate for Payer: Anthem Medicare Advantage |
$1,402.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,105.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,402.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,402.74
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,918.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,402.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,166.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,402.74
|
| Rate for Payer: Health EOS Commercial |
$1,855.83
|
| Rate for Payer: HFN Commercial |
$1,918.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,218.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,402.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,402.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,402.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,402.74
|
| Rate for Payer: Multiplan Commercial |
$1,668.16
|
| Rate for Payer: NAPHCARE Commercial |
$2,104.11
|
| Rate for Payer: Preferred Network Access Commercial |
$1,918.38
|
| Rate for Payer: Quartz Beloit One Network |
$1,021.75
|
| Rate for Payer: Quartz Commercial |
$1,355.38
|
| Rate for Payer: Quartz Medicare Advantage |
$1,402.74
|
| Rate for Payer: The Alliance Commercial |
$5,610.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,402.74
|
| Rate for Payer: WEA Trust Commercial |
$1,146.86
|
| Rate for Payer: Wellcare Medicare |
$1,402.74
|
| Rate for Payer: WPS Commercial |
$1,544.45
|
|
|
Yes - EMS Arrival with Notification Level 3*
|
Facility
|
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
4962608
|
|
Hospital Revenue Code
|
683
|
| Min. Negotiated Rate |
$1,021.75 |
| Max. Negotiated Rate |
$1,918.38 |
| Rate for Payer: Aetna Commercial |
$1,876.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,793.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,105.16
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,918.38
|
| Rate for Payer: Health EOS Commercial |
$1,855.83
|
| Rate for Payer: HFN Commercial |
$1,918.38
|
| Rate for Payer: Multiplan Commercial |
$1,668.16
|
| Rate for Payer: Preferred Network Access Commercial |
$1,918.38
|
| Rate for Payer: Quartz Beloit One Network |
$1,021.75
|
| Rate for Payer: Quartz Commercial |
$1,251.12
|
| Rate for Payer: WEA Trust Commercial |
$1,146.86
|
| Rate for Payer: WPS Commercial |
$1,544.45
|
|
|
Yes - Endotracheal Tube Holder Charge
|
Facility
|
IP
|
$29.00
|
|
| Hospital Charge Code |
2990201
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$18.10
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
Yes - Endotracheal Tube Holder Charge
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
2990201
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Aetna Managed Medicare |
$8.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.88
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.62
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: NAPHCARE Commercial |
$18.10
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$19.60
|
| Rate for Payer: Quartz Medicare Advantage |
$18.10
|
| Rate for Payer: The Alliance Commercial |
$15.08
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
Yes - ETCO2 Adapter Charge
|
Facility
|
IP
|
$101.00
|
|
| Hospital Charge Code |
3006950
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$51.47 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$63.02
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
Yes - ETCO2 Adapter Charge
|
Facility
|
OP
|
$101.00
|
|
| Hospital Charge Code |
3006950
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Aetna Managed Medicare |
$29.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.78
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.78
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: NAPHCARE Commercial |
$63.02
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$68.28
|
| Rate for Payer: Quartz Medicare Advantage |
$63.02
|
| Rate for Payer: The Alliance Commercial |
$52.52
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
Yes - ETCO2 Adult Oxymask Charge
|
Facility
|
OP
|
$153.00
|
|
|
Service Code
|
HCPCS A4620
|
| Hospital Charge Code |
5543166
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Aetna Managed Medicare |
$44.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.05
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.34
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: NAPHCARE Commercial |
$95.47
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$103.43
|
| Rate for Payer: Quartz Medicare Advantage |
$95.47
|
| Rate for Payer: The Alliance Commercial |
$3.79
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
Yes - ETCO2 Adult Oxymask Charge
|
Facility
|
IP
|
$153.00
|
|
|
Service Code
|
HCPCS A4620
|
| Hospital Charge Code |
5543166
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.97 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$95.47
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
Yes - ETCO2 Cannula Charge
|
Facility
|
IP
|
$101.00
|
|
| Hospital Charge Code |
3006951
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$51.47 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$63.02
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
Yes - ETCO2 Cannula Charge
|
Facility
|
OP
|
$101.00
|
|
| Hospital Charge Code |
3006951
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Aetna Managed Medicare |
$29.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.78
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.78
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: NAPHCARE Commercial |
$63.02
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$68.28
|
| Rate for Payer: Quartz Medicare Advantage |
$63.02
|
| Rate for Payer: The Alliance Commercial |
$52.52
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
Yes - ETCO2 Peds Oxymask
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS A4620
|
| Hospital Charge Code |
5543161
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Aetna Managed Medicare |
$47.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$84.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.87
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.14
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: NAPHCARE Commercial |
$101.71
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$110.19
|
| Rate for Payer: Quartz Medicare Advantage |
$101.71
|
| Rate for Payer: The Alliance Commercial |
$3.79
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
Yes - ETCO2 Peds Oxymask
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS A4620
|
| Hospital Charge Code |
5543161
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.06 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$101.71
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
Yes - Evaluation for Non-Speech Device
|
Facility
|
OP
|
$425.00
|
|
|
Service Code
|
CPT 92505 GN
|
| Hospital Charge Code |
2987933
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$123.76 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Aetna Commercial |
$397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$380.12
|
| Rate for Payer: Aetna Managed Medicare |
$123.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.26
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$406.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$247.35
|
| Rate for Payer: Health EOS Commercial |
$393.38
|
| Rate for Payer: HFN Commercial |
$406.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: NAPHCARE Commercial |
$265.20
|
| Rate for Payer: Preferred Network Access Commercial |
$406.64
|
| Rate for Payer: Quartz Beloit One Network |
$216.58
|
| Rate for Payer: Quartz Commercial |
$287.30
|
| Rate for Payer: Quartz Medicare Advantage |
$265.20
|
| Rate for Payer: The Alliance Commercial |
$221.00
|
| Rate for Payer: United Healthcare PPO |
$331.50
|
| Rate for Payer: WEA Trust Commercial |
$243.10
|
| Rate for Payer: WPS Commercial |
$327.38
|
|
|
Yes - Evaluation for Non-Speech Device
|
Facility
|
IP
|
$425.00
|
|
|
Service Code
|
CPT 92505 GN
|
| Hospital Charge Code |
2987933
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$216.58 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Aetna Commercial |
$397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.26
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$406.64
|
| Rate for Payer: Health EOS Commercial |
$393.38
|
| Rate for Payer: HFN Commercial |
$406.64
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: Preferred Network Access Commercial |
$406.64
|
| Rate for Payer: Quartz Beloit One Network |
$216.58
|
| Rate for Payer: Quartz Commercial |
$265.20
|
| Rate for Payer: WEA Trust Commercial |
$243.10
|
| Rate for Payer: WPS Commercial |
$327.38
|
|
|
Yes - Evaluation for Speech Device
|
Facility
|
IP
|
$915.00
|
|
|
Service Code
|
CPT 92607 GN
|
| Hospital Charge Code |
2987934
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$466.28 |
| Max. Negotiated Rate |
$875.47 |
| Rate for Payer: Aetna Commercial |
$856.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.35
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$875.47
|
| Rate for Payer: Health EOS Commercial |
$846.92
|
| Rate for Payer: HFN Commercial |
$875.47
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: Preferred Network Access Commercial |
$875.47
|
| Rate for Payer: Quartz Beloit One Network |
$466.28
|
| Rate for Payer: Quartz Commercial |
$570.96
|
| Rate for Payer: WEA Trust Commercial |
$523.38
|
| Rate for Payer: WPS Commercial |
$704.82
|
|
|
Yes - Evaluation for Speech Device
|
Facility
|
OP
|
$915.00
|
|
|
Service Code
|
CPT 92607 GN
|
| Hospital Charge Code |
2987934
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$875.47 |
| Rate for Payer: Aetna Commercial |
$856.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.38
|
| Rate for Payer: Aetna Managed Medicare |
$266.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.35
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$875.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.53
|
| Rate for Payer: Health EOS Commercial |
$846.92
|
| Rate for Payer: HFN Commercial |
$875.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: NAPHCARE Commercial |
$570.96
|
| Rate for Payer: Preferred Network Access Commercial |
$875.47
|
| Rate for Payer: Quartz Beloit One Network |
$466.28
|
| Rate for Payer: Quartz Commercial |
$618.54
|
| Rate for Payer: Quartz Medicare Advantage |
$570.96
|
| Rate for Payer: The Alliance Commercial |
$475.80
|
| Rate for Payer: United Healthcare PPO |
$713.70
|
| Rate for Payer: WEA Trust Commercial |
$523.38
|
| Rate for Payer: WPS Commercial |
$704.82
|
|
|
Yes - EZPAP Setup Charge
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
3006985
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$143.20 |
| Max. Negotiated Rate |
$268.86 |
| Rate for Payer: Aetna Commercial |
$263.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.89
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$268.86
|
| Rate for Payer: Health EOS Commercial |
$260.09
|
| Rate for Payer: HFN Commercial |
$268.86
|
| Rate for Payer: Multiplan Commercial |
$233.79
|
| Rate for Payer: Preferred Network Access Commercial |
$268.86
|
| Rate for Payer: Quartz Beloit One Network |
$143.20
|
| Rate for Payer: Quartz Commercial |
$175.34
|
| Rate for Payer: WEA Trust Commercial |
$160.73
|
| Rate for Payer: WPS Commercial |
$216.45
|
|
|
Yes - EZPAP Setup Charge
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
3006985
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$140.28 |
| Max. Negotiated Rate |
$921.81 |
| Rate for Payer: Aetna Commercial |
$263.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.33
|
| Rate for Payer: Aetna Managed Medicare |
$230.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$189.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$146.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$140.28
|
| Rate for Payer: Anthem Medicare Advantage |
$230.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$230.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$230.45
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$268.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$230.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$163.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$230.45
|
| Rate for Payer: Health EOS Commercial |
$260.09
|
| Rate for Payer: HFN Commercial |
$268.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$857.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$230.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$230.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$230.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$230.45
|
| Rate for Payer: Multiplan Commercial |
$233.79
|
| Rate for Payer: NAPHCARE Commercial |
$345.68
|
| Rate for Payer: Preferred Network Access Commercial |
$268.86
|
| Rate for Payer: Quartz Beloit One Network |
$143.20
|
| Rate for Payer: Quartz Commercial |
$189.96
|
| Rate for Payer: Quartz Medicare Advantage |
$230.45
|
| Rate for Payer: The Alliance Commercial |
$921.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$230.45
|
| Rate for Payer: United Healthcare PPO |
$219.18
|
| Rate for Payer: WEA Trust Commercial |
$160.73
|
| Rate for Payer: Wellcare Medicare |
$230.45
|
| Rate for Payer: WPS Commercial |
$216.45
|
|
|
Yes - EzPAP Treatment, subsequent Charge
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
3023870
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$55.91 |
| Max. Negotiated Rate |
$921.81 |
| Rate for Payer: Aetna Commercial |
$104.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$100.17
|
| Rate for Payer: Aetna Managed Medicare |
$230.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$75.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$58.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.91
|
| Rate for Payer: Anthem Medicare Advantage |
$230.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$230.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$230.45
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$107.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$230.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$230.45
|
| Rate for Payer: Health EOS Commercial |
$103.67
|
| Rate for Payer: HFN Commercial |
$107.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$857.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$230.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$230.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$230.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$230.45
|
| Rate for Payer: Multiplan Commercial |
$93.18
|
| Rate for Payer: NAPHCARE Commercial |
$345.68
|
| Rate for Payer: Preferred Network Access Commercial |
$107.16
|
| Rate for Payer: Quartz Beloit One Network |
$57.08
|
| Rate for Payer: Quartz Commercial |
$75.71
|
| Rate for Payer: Quartz Medicare Advantage |
$230.45
|
| Rate for Payer: The Alliance Commercial |
$921.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$230.45
|
| Rate for Payer: United Healthcare PPO |
$87.36
|
| Rate for Payer: WEA Trust Commercial |
$64.06
|
| Rate for Payer: Wellcare Medicare |
$230.45
|
| Rate for Payer: WPS Commercial |
$86.27
|
|
|
Yes - EzPAP Treatment, subsequent Charge
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
3023870
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$107.16 |
| Rate for Payer: Aetna Commercial |
$104.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$100.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.73
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$107.16
|
| Rate for Payer: Health EOS Commercial |
$103.67
|
| Rate for Payer: HFN Commercial |
$107.16
|
| Rate for Payer: Multiplan Commercial |
$93.18
|
| Rate for Payer: Preferred Network Access Commercial |
$107.16
|
| Rate for Payer: Quartz Beloit One Network |
$57.08
|
| Rate for Payer: Quartz Commercial |
$69.89
|
| Rate for Payer: WEA Trust Commercial |
$64.06
|
| Rate for Payer: WPS Commercial |
$86.27
|
|
|
Yes - Facetent Charge
|
Facility
|
IP
|
$77.00
|
|
| Hospital Charge Code |
3006953
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$48.05
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Yes - Facetent Charge
|
Facility
|
OP
|
$77.00
|
|
| Hospital Charge Code |
3006953
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Aetna Managed Medicare |
$22.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.81
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.06
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: NAPHCARE Commercial |
$48.05
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$52.05
|
| Rate for Payer: Quartz Medicare Advantage |
$48.05
|
| Rate for Payer: The Alliance Commercial |
$40.04
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Yes - Flutter Valve Charge
|
Facility
|
OP
|
$118.00
|
|
| Hospital Charge Code |
3610752
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$34.36 |
| Max. Negotiated Rate |
$112.90 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Aetna Managed Medicare |
$34.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.68
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.04
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: NAPHCARE Commercial |
$73.63
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$79.77
|
| Rate for Payer: Quartz Medicare Advantage |
$73.63
|
| Rate for Payer: The Alliance Commercial |
$61.36
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
